HomeMy WebLinkAboutZoniing Compliiance DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE
TYPE OF APPLICATION
Temporary Permit [ Special Sales License
,,SECTION IIA: APPLICANT INFORMATION
Full Name of Applicant(s)
The permit will be issued in the name of the applicant as provided on the application.
Nettles Island Spring Festival
Applicant Mailing Address
9801 S Ocean Drive
City County State Zip Code
Jensen Beach St Lucie FL 34957
Applicant Telephone Number Applicant E-mail Address
772-208-7929 NIFestivaIChair@gmail.com
Corporation or Other Legal Entity
If the applicant is a corporation or other legal entity,enter the name and the document number related to the legal entity as
registered with the Florida Department of State Division of Corporations.
FEIN Number Florida Department of State Document Number
SECTION 18(OPTIONAL): DESIGNATED CONTACT
A contact person must be designated below if the applicant prefers to designate a person other than the applicant to receive and
reply to Division communications regarding this application. The designated contact person will be permitted to make changes to
the application paperwork on behalf of the applicant,and the Division will communicate directly with the contact person regarding
the application. The applicant will not be copied on communications from the Division to the designated contact. It is the
responsibility of the applicant to inform the Division if there is a change of designated contact and/or to the contact information of the
designated contact.
Full Name of Designated Contact
Debra Reese
Designated Contact Mailing Address
810 Nettles Blvd
City County State Zip Code
Jensen Beach St Lucie FL 34957
Designated Contact E-mail Address Designated Contact Telephone Number
NlFestivalchair@gmail.com 616-481-6224 Ext.
INCORPORATED BY REFERENCE:61A-5.0013,F.A.C. EFFECTIVE 912019
DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE
...SE.oON42 P CESA%hgg1 lON qF R_P ,RMIT OR LICENSE
Dates of Active Use for Temporary Permit or Special Sales License
Provide the dates of the event or sale when the permit or license will be effective. The dates provided may not exceed three days.
Day 1 Day 2 Day 3
March 19, 2021 March 20,2021 March 21, 2021
Address for Physical Location of Temporary Event or Special Sales Event
9801 S Ocean Drive
City County State Zip Code
Jensen Beach St Lucie FL 34957
Is the event location currently licensed for sales of alcoholic beverages under a permanent
license issued by the Division? Yes ■0 No 9 if yes,obtain attestation of permanent license holder in Section 8.
SECTION 3:SALES TAX CERTIFICATION T
TO BE COMPLETED BY THE FLORIDA DEPARTMENT OF REVENUE
Full Name of Applicant(s)
Nettles Island Spring Festival
Florida Department of Revenue Verification of Registration
The named applicant(s)for a temporary permit or special sales license has complied with Florida
Statutes concerning registration for Sales and Use Tax and has paid or agreed to pay any applicable
taxes due.
Authorized Agency Signature
Printed Name
Title
Date
INCORPORATED BY REFERENCE:61A-5.0013, F.A.C. EFFECTIVE 9I2019
DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE
SECTION 4: LOCAL ZONING APPROVAL
,TO BE COMPLETED BY THE ZONING AUTHORITY GOVERNING THE TEMPORARY EVENT LOCATION''
Location of Temporary Event
Street Address
9801 S Ocean Drive
City County State Zip Code
Jensen Beach St Lucie FL 34957
Local Zoning Approval
The location of the temporary event complies with local ordinances for the temporary sale of alcoholic
beverages based on the information supplied by the applicant in this application.
Authorized Agency Signature
Printed Name
11 i EL''P�rV15b,
Title (M�2 1 no ?,on L nr,
Date I l 1 dam(
INCORPORATED BY REFERENCE:61A-5.0013, F.A.C. EFFECTIVE 9/2019
DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE
Full Name of Applicant(s)
Nettles Island Spring Festival
Name or Title of Temporary Event
Nettles Island Spring Festival
Neatly draw a floor plan of the premises in ink,including:sidewalks and other outside areas which are contiguous to the premises,
walls,doors,counters,points of sale of alcoholic beverages,storage areas,restrooms,bar locations,and any other specific areas
which are part of the premises where the event will be held. A multi-story building where the entire building is to be licensed must
show the details of each floor.
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INCORPORATED BY REFERENCE:61A-5.0013, F.A.C. EFFECTIVE 9/2019
DBPR ABT— 6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE
SECTION 6: AFFIDAVIT OF APPLICANT FOR TEMPORARY PERMIT
NOTARIZATION REQUIRED
Full Name of Applicant(s)
Nettles Island Spring Festival
"The applicant requesting the permit in the above and foregoing application is a nonprofit civic organization,charitable organization,
municipality or county,and the permit,if used,will be used only by the applicant organization on the date(s)requested and at the
location stated.By acceptance of this permit,the applicant agrees that,as a nonprofit or civic organization,all net profits from sales
of alcoholic beverages during the permitted period will be retained by it,or,as a municipality or county,all net profits from sales of
alcoholic beverages during the permit period will be donated to a nonprofit civic or charitable organization within 90 days after the
permitted event. As a municipality or county,the applicant attempted to solicit a qualified nonprofit civic or charitable organization to
conduct such sales for the permitted event but has been unable to find such a qualifying nonprofit civic or charitable organization in a
reasonable and practicable manner and timeframe.The applicant organization has not received more than twelve(12)permits within
the calendar year,unless otherwise authorized by law,and the applicant agrees that the location may be inspected and searched
during the time that the permit is issued and business is being conducted without a search warrant by authorized agents or
employees of the Division of Alcoholic Beverages and Tobacco,the Sheriff,Deputies,and Police Officers for purposes of
determining compliance with the Florida Beverage Law.
I,the undersigned individual,or if a corporation,for itself,its officers and directors,hereby swear or affirm that I am duly authorized to
make the above and foregoing application and,as such,I swear under oath or affirmation under penalty of perjury as provided for in
sections 559.791,562.45,and 837.06,Florida Statutes,that the foregoing information is true and correct."
Signature of Applicant/Affiant
STATE OF
COUNTY OF
Sworn to(or affirmed)and subscribed before me this day of 20
by (print affiant name).
( ) Personally Known
( ) Produced Identification
Type of Identification Produced
Signature of Notary Public—State of Florida
Name of Notary Public—Typed, Printed, or Stamped
(NOTARY SEAL) Commission Expires:
FOR DIVISION USE ONLY
DATE ACCEPTED BY DISTRICT OFFICE:
INCORPORATED BY REFERENCE:61A-5.0013, F.A.C. EFFECTIVE 912019
DBPR ABT —6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE
SECTION 7. AFFIDAVIT OF APPLICANT FOR SPECIAL SALES LICENSE
' - NOTARIZATION REQUIRED
Full Name of Applicant(s)
Nettles Island 9pFi4g "fin%s CtLtCJ
"As the applicant requesting the special sales license in the above and foregoing application,I understand that this license allows
package sales in sealed containers for a period of up to three days,and does not permit the sale of alcoholic beverages for
consumption on the premises.I agree that the location may be inspected and searched during the hours that the special sale is
being conducted without a search warrant by authorized agents or employees of the Division of Alcoholic Beverages and Tobacco,
the Sheriff,Deputies,and Police Officers for purposes of determining compliance with the Florida Beverage Law.
i,the undersigned individual,or if a corporation,for itself,its officers and directors,hereby swear or affirm that I am duly authorized to
make the above and foregoing application and,as such,I swear under oath or affirmation under penalty of perjury as provided for in
sections 559.791,562.45,and 837.06,Florida Statutes,that the forego g information is true and correct."
Signature of Applicant/Affiant
STATE OF ( {
COUNTY OF
Sworn to(or affirmed)and subscribed before me this day of ��1� 1� t��1 20
by 1C�1 L (print affiant name).
( ) Personally Known
( ) Produced Identification
Type of Identification Produced
—0 It
Signature of Notary Public—State of Florida
� Y►u CARLA NELSON Name of Notary Public—Typed, Printed, or Stamped
?�• `F`: Notary Public•State of Florida
o Commission#HH 39493
or ies$ep 3,2024
soni aXt't kary Assn. Commission Expires:
FOR DIVISION USE ONLY
DATE ACCEPTED BY DISTRICT OFFICE:
INCORPORATED BY REFERENCE: 61A-5.0013, F.A.C. EFFECTIVE 9/2019
DBPR ABT—6003 APPLICATION FOR TEMPORARY PERMIT OR SPECIAL SALES LICENSE
SECTION 8: ATTESTATION BY PERMANENT LICENSE HOLDER
FOR USE OF LICENSED PREMISES AS A PERMITTED TEMPORARY EVENT
An attestation is to be obtained from the current,permanent alcoholic beverage license holder when the temporary event of the
applicant nonprofit civic organization,charitable organization,municipality,or county is hosted at a location that is permanently
licensed by the Division of Alcoholic Beverages&Tobacco for the sale of alcoholic beverages.
NOTE:The attestation must have the original signature of the alcoholic beverage license holder(only persons on file with the
Division may sign)and must be submitted by the nonprofit civic organization,charitable organization,municipality,or county as part
of the application for the Temporary Permit.
Full Name of Permanent License Holder at Temporary Event Location
Nettles Island Men's Club
Business Name(D/B/A)
License Number Series of Permanent License
BEV5302588 Series 11 Type: C
Contact Person for Permanent License Holder Contact Person Telephone Number
Dick Bellavance 7742541638 Ext.
Contact Person E-mail Address
n/a
Name of Applicant for Temporary Permit
Nettles Island Spring Festival
Date(s)of Temporary Event
Day 1 Day 2 Day 3
March 19, 2021 March 20, 2021 March 21, 2021
A temporary permit is being requested for an event to be held on your licensed premises. During the
permitted dates and times of the event, no sales or service of alcoholic beverages may be made under
your permanent alcoholic beverage license in the area identified for use by the temporary permit applicant
in Section 5 of this application. Failure to comply may result in administrative charges being filed against
your license. j
Date V
Signature of Permanent License Holder at Temporary Event Location
�cbard ;RQ 1 la gaYnc-e
Printed Name of Permanent License Holder at Temporary Event Location
INCORPORATED BY REFERENCE: 61A-5.0013, F.A.C. EFFECTIVE 9/2019